Is It Bipolar Or Substance Use?

Sixteen psychiatrists we have interviewed are changing their approach to diagnosing bipolar, substance use and other mood disorders, which for policy makers and insurers ought to matter and may be an impetus for higher reimbursement if the changes lead to faster and better outcomes for patients. 

The backstory: substances can look like mania and mania can drive substance use, according to Dr. Daniel Suter, a psychiatrist. He says this complicates diagnostics. Take cocaine or alcohol withdrawal - both lead to agitation, emotional volatility, decreased sleep.

But bipolar can lead to substance use, and a manic episode can make alcohol or drug use more likely, notes psychiatrist Valerie Kalan.  Suter says psychiatrists shouldn't dismiss bipolar just because substances are involved, but they also shouldn't fully trust a bipolar label until they can determine the timeline, "like if the patient's mood episode occurs during sustained sobriety," or if the patient arrives depressed: is it bipolar depression or substance-induced mood disorder, or trauma plus sleep disruption? It may be a combination and the answers matter - they change the treatment plan.

The goal is to get the right diagnosis before years of mistreatment, which 13 of 16 said is happening way too often, and payers have said will matter more as they look to the industry to get patients to goal quicker.